This is the fifth article in the series that discusses the CRM program in detail and explores how it can be applied to our business.Some incident commanders like being in the (actual) heat of battle at every alarm. This type of boss will express a desire to get a good look inside ("up close and personal, leave nothing to chance", an old chief would say to me as he entered the smoke). The same type personality flaw wants to be the public information officer, engage in "hands-on" patient care and perhaps be the interior operations supervisor, without ever transferring command to anyone else. This "super-charged solo fighter pilot" seems to be able to do it all, except to provide continuous, high quality command and control of an incident scene. There is an emerging process that causes the individual responsible for a high-risk event (such as a fire or rescue alarm) to utilize all available resources to safely, effectively and efficiently resolve the problem at hand. The system that I have described is the commercial airline industry's Crew Resource Management (CRM) process. This is the fifth article in the series that discusses the CRM program in detail and explores how it can be applied to our business (fire-rescue command). The topic of discussion for this issue will be the proper allocation of tasks by the incident commander to his/her supporting cast of characters.
Brief Review of CRM
Crew Resource Management was born in December of 1978 out of the growing necessity to lower (actually eliminate) commercial airplane crashes. Scientific research clearly determined that more than 80% of all commercial aviation disasters were caused directly by human error problems. The case study that pushed the Federal Aviation Administration (FAA) into action was a DC - 8 that ran out of fuel 6 miles out from the airport after circling for nearly one hour (United 173). The crew advised the captain of the low fuel situation, but he did not hear the dozen or so warnings given to him by his crew. The research indicated that in retrospect, the human error that cost ten lives that day was highly predicable before impact. In other words, none of the investigators were surprised that the plane would run out of fuel after the first and second officers repeatedly warned the captain of the remaining fuel status. When the captain refused the input and participation of the qualified crew members, the odds were that a disaster would catch-up to this pilot. When the pilot least expected it, an unimaginable disaster occurred because of his inability to effectively use his crew's input (a classic human error).
Key Elements
With the correct tools and motivation, human behaviors can be changed in a positive way. The FAA along with the airline industry developed and implemented the program that is now known as Crew Resource Management. The program is simple, straightforward and most importantly effective when properly applied to daily operations. This concept is not a "flash in the pan" or a "passing fad" for the airline industry. Human performance is watched from every angle by the airlines, with an eye towards constant improvement. There is too much at risk to take this improvement process lightly. In fact, CRM is now in its sixth major revision after 23 years of documented use. (Author's note: Sounds like our business, high risk!).
The key elements of CRM are:
• Effective Communications
• Teamwork/Leadership
• Task Allocation
• Critical Decision Making
Classic Aviation Case Study
In December of 1972, an Eastern Airlines flight departed in route to Miami. The filed flight pattern had the Lockheed TriStar 1011 wide body jet flying directly over the heart of the Everglades into south Florida. While at 2,000 feet on its final approach for landing, it was noticed that the nose landing gear light was not lit. The decision was correctly made to go into a holding pattern while the problem was diagnosed and resolved. The second officer (flight engineer) crawled into the below deck access area (better known as the "hell hole"). He tried to get a visual inspection to insure that the nose gear was down and hopefully locked into place. The captain and co-pilot focused on the efforts of the flight engineer as he did the visual inspection of the nose gear. While the captain was leaning in to talk to the engineer, he inadvertently pushed in on the yoke, which disengaged the autopilot function.
Once the autopilot was disengaged, the plane gradually descended without the crew noticing. During the time that no one was flying the plane, it continued to drop from the sky, until there was a high impact crash. The plane came in contact with the terrain under full power in a most unfriendly place, deep in the Everglades. The National Transportation Safety Board's (NTSB) findings indicated that the crash of Eastern 401 was due to human error. "Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed", so said the final NTSB report. Essentially, there was no pilot flying the plane at the time of impact. The plane performed exactly as it was designed to and had no mechanical problems, except for a 59-cent burned out light bulb. The pilot forgot to assign the critical task to fly the ship during the period that his focus was elsewhere. The airline industry has a little saying that is worth repeating at this point. They regularly remind pilots (after this unfortunate incident) that they must always execute the basics of flying by:
• Aviate (fly the plane)
• Navigate (know where you are headed)
• Communicate (keep all parties informed)
The industry's efforts must have paid off, because in a recent mechanical failure situation that doomed a flight, the crew stuck to flying the plane even thought they knew that it was an impossible situation.
Rules for Task Allocation
Now, let's apply this information, task allocation, to the incident management process. There are five major principals of task allocation. These five principals are:
1. Attitude/desire to delegate duties to subordinates by the I/C and other key command system players.
2. Clearly defined roles and responsibilities that are to be delegated to other members at alarms.
3. Provide the proper staffing levels and other support that is necessary to perform the jobs that have been delegated.
4. Develop, implement and use initial response guidelines for first alarm companies.
5. Members that are required to handle a specific task situation should (if at all possible) be well trained to perform what is requested/expected of them (flawlessly execute the basics).
A major part of the price of being able to do business in a safe, effective and efficient way is that the incident commander must be willing to properly delegate duties to other members. The incident commander must quickly develop an organizational structure that can handle the needs of our customers, keeping in mind the various timeline requirements (such as the "golden hour" or the time temperature curve impact). The allocation of tasks can be rather simple or very complex solely based upon the challenges of the incident. The big boss (I/C) must be trained in how to properly use all of the talents of the group that is assembled to handle the call for help. The commander cannot be allowed to fall into the trap of "going inside for a look" or giving just a brief media report at the big ones. If the incident commander is lulled into thinking that he/she can do it all (or nearly all) the scene will most likely fall apart. After the situation is allowed to get out of control, it is highly unlikely that it will ever get back on track. That reminds me of a true saying from a very wise and capable I/C? "First you loose your head, then you loose your a_ _?"
Reflecting back to the aviation industry's simple list of the basics, I submit that the fire - rescue services list for properly commanding an incident should be:
• Command/Control/Coordinate
• Stay focused/Pay attention all of the time
• Communicate
One way to keep the commander near the command post and thinking about the job tasks assigned to him/her is to use a radio headset. The concept is that the headset wire becomes a "set of handcuffs" to keep the boss at the command post and in charge. It is tough to wear the headset with a ten-foot cord and crawl down the hallway at the same time. Along with the "leash" concept, the mobile radio is more capable than are the portables (usually 3 watts of power versus 30 watts) with the mobiles being much more powerful and effective.
Next, the job assignments that are delegated need to be well defined. The member that receives specific duties and responsibilities needs to have a complete understanding of what is expected of him/her to accomplish. Interestingly, I have taught dozens of safety officer classes across America. When the program starts, the standard rhetorical question is asked? "Is firefighter safety important"? ? The group always agrees that it is the number one critical concern. The follow-up question is next asked, ? "Who has been trained in the roles of the safety officer?" And, only a few hands get raised. Wow! Isn't it interesting that we don't train our troops for this most important function?
As an example, the job responsibility of a safety officer at a structural fire should include items like: take a 360-degree view of the entire incident; watch out for and prevent unsafe acts, unsafe conditions and unsafe behaviors and secure the scene to deny access to onlookers. The expected duties of the various assigned positions should be recorded in a standard operating procedure (SOP). Organizational training must be held so that the members that are asked to fill a position understand their responsibilities. Just like the unscientific survey that I conduct, many of the people do not understand, nor are they trained to do their assigned job. To add insult to injury, when I have asked the untrained safety officers what directions do they receive from the I/C, it sounds something like "keep us safe". This vague, generalization of the safety officer's duties seems to say that this role is established to just check a box and there is no real desire for improvement.
The likelihood that tasks will be handled properly improves when the roles and responsibilities delegated to members are clearly defined. Training will improve the level of confidence that most incident commanders should have in their support troops and that they have in themselves performing assigned tasks. When the time and effort is taken to document and train on the important skills that are required to run an event, significant improvement will follow.
Although it may sound a little basic to point out, but the proper level of staffing is a requirement to be successful at providing fire and rescue services. A critical element of task allocation is to insure that the proper level of staffing is obtained and maintained for as long as the help are needed. While teaching "CRM" classes, I describe the need for a minimum command team of four members at all multi-company responses. This four-member team consists of an incident commander, senior advisor, accountability officer, and a safety officer. The reaction to this statement is interesting to say the least. Some class members point out that they do not have four members assigned to a shift or that only four members (on average) turnout on daytime alarms (volunteer and on call systems). All are valid points, but the organization has the responsibility to make sure that the proper level of staffing is identified and dispatched. Maybe the solution could be to call for mutual aid or even develop an automatic aid program. Regardless of how the correct (qualified) numbers of operational personnel are obtained, they must be present at the incident. Keep in mind that the department must comply with the "2in/2out" law as well as the soon to be published NFPA 1710 standard. Our work is labor intensive to perform skills that are required to resolve a situation that we are called upon to fix.
Next, I would strongly suggest that a detailed set of initial guidelines (see figure 1) be developed and implemented for the typical situations that your companies respond to regularly. For instance, guidelines should cover structural fires, hazardous materials alarms and the like. The initial guideline will be a great help in getting the operation off to a strong and correct start every time. There should be no surprises as to what is expected from an operating company at the start of an alarm. Everyone should know their role or they should be assigned to staging until command has the time (sometimes a luxury) to determine what, where, when and who. Any responding officer can change the initial guidelines, if the situation warrants and the change can be justified. Once the initial plan is amended, the officer making the change is responsible to insure that all incoming units understand the change and how they fit into the new plan. Without having clear initial guidance, this author has observed four in-bound engine companies failing to lay a supply line at a significant working fire on more than one occasion. When asked why, the typical officer's response is that they thought that some other company was going to handle water supply (the concept of who is flying the plane comes to mind).
Finally, the members that are given a specific assignment need to be training in the proper collection of skills to perform the tasks that they are assigned to handle. Sometimes, members are given tasks that they are not prepared (trained, educated and experienced) to handle. Again, the safety officer role that was mentioned earlier in this article comes to mind. Telling the newly appointed safety officer to "keep us safe" is a good start, but it is simply not enough. Without the proper preparation, assigning the unqualified is no more than merely checking the box on a command chart. By comparison, commercial airline pilots are checked and tested four times a year (every year) to make sure that they still know how to fly their plane. We could learn a lot from this industry as it relates to certifications and day-to-day operations.
Path for Improvement
To summarize, the CRM process is a simple and very effective way to improve firefighter health and safety at incidents. The proper and consistent use of this process will allow an organization to be better able to assist their customers in just about every phase of service delivery. That is a hard combination (safer and better) to beat by any standard. Understanding that proper task allocation is a critical element in the operational success at an alarm is a great place to start. Command officers must review and use the five principals of task allocation to be efficient, effective and safe at all incidents. Finally, development and implementation on initial guidelines are critical components of properly assigned tasks to companies at all types of emergencies.
A quick review of just about any NIOSH firefighter fatality report will most likely indicate that the direct cause of the death(s) was human error. The "red ink" (causal factors) page of the NIOSH reports list items such as failure to implement incident command, no safety officer identified, no member accountability and failure to properly communicate repeatedly. By consistently using the tools that CRM provides we can lower (hopefully eliminate) firefighter injuries and fatalities. It would seem logical that at least 80 percent of failures (human errors) could be eliminated by the incident command system enhancement "Crew Resource Management". Until next time, be safe out there!
